Naval Medical Center San Diego Department of Pediatrics

Newborn Care Guide

December 2006
Dr. Mike Dubik & Dr. Joel Ruff

House Staff and Medical Students

This booklet is intended to serve as a central source of basic information to help you advise parents through the first few weeks. Suggestions for improving or updating this guide should be directed toward the Head, Newborn Nursery (currently Dr. Ruff), who is responsible for all future revisions. This guide should be updated at least annually. Bathing: Until the umbilical cord comes off, bathing should be limited to sponge bathing. A mild soap, such as unscented Dove or Tone, is recommended; harsh soaps, like deodorant or perfumed soaps should be avoided. The babys face should be washed with plain water. A bath 2 to 3 times a week is usually enough. The diaper area should be cleaned with a warm, soft washcloth or alcohol free wipes after every change. If baby is on a surface above the floor (i.e., on a table for a sponge bath), always keep one hand on the baby to prevent falls. Behavior: Some of the things that newborn babies do can concern parents, when really these behaviors are normal, and not a sign of illness. Most are caused by harmless, immature reflexes, and disappear in 2 or 3 months. Some of these behaviors include: Chin trembling Lower lip quivering Frequent yawning Hiccups Passing Gas Noises caused by breathing or movement during sleep Sneezing Spitting up (small amounts) or burping Startle reflex -- a quick stiffening of the body in response to loud sounds or sudden movement Straining with bowel movements Throat clearing or gurgling sounds caused by secretions in the throat. These are not cause for concern unless the baby is having difficulty breathing. Irregular Breathing -- not a cause for concern as long as your baby is content, her breathing rate is less than 60 breaths per minute, pauses between breaths last less than 6 seconds, and she doesnt turn blue. Occasionally, infants take rapid, progressively deeper breaths to completely expand the lungs. Trembling or jitteriness of the arms and legs during crying

Body hair (lanugo): Lanugo is the fine, downy hair that may be present on the shoulders and backs of newborn babies. It is more common in premature babies. It is generally gone by 2-4 weeks of age. Birth Weight: The average birth weight for a baby is about 7 lbs (3.2 kg). Boys are usually a little heavier than girls. The baby will probably measure between 18 and 22 inches in length (45 to 56 cm). The head comprises about of the entire length. A newborn initially loses weight but usually catches back up to birth weight within two weeks. The babys weight usually doubles by 4 to 5 months and triples by one year. Bowel Movements: Babies can show quite a lot of variation in their bowel movements (BMs). 6 BMs a day or more to 1 BM every six days can all be normal. Straining with stooling is also normal since it is difficult to poop, if all you consume is milk, while lying on your back. Stool color varies between brown, green, and yellow. The only bad colors are red (blood) or white (blockage in the liver), or black (digested blood). Baby stools are usually soft, similar to applesauce consistency. Breastfed babies rarely suffer from constipation. If the parents report that the baby appears extremely uncomfortable or if they think blood is in the stools, the baby should be seen. Breastfeeding: This is the ideal and natural feeding method for babies during the first year and is recommended by the AAP, the ACOG, and the American Dietetic Association. Babies fed breast milk enjoy numerous benefits, including fewer infections and allergies. Breastfeeding is good for mothers, too. Mothers who breastfeed return to their prepregnancy weight sooner and may form closer bonds to their babies. Breast milk production works, basically, on a supply-and-demand principle. Therefore, recommend feeding on demand. From birth a baby may nurse as long as she wants. A baby usually gets all the milk she needs in the first 15 minutes or so of vigorous sucking. Nevertheless, individual feeding times can vary. The quality of the time spent nursing is the most important aspect -actively transferring milk vice sleeping or pacifying at the breast. You can expect the baby to feed 8 to 12 times a day. Mom should alternate which breast is offered first. Getting Started: The baby can be placed on mom's chest or abdomen immediately after birth. Babies are often born quite alert and hungry, so the first feeding can take place within the first hour after delivery. The preferred breastfeeding position for a first time mother is the football or cross cradle hold. This position allows the mother to have a good view of the babys latch and it promotes eye contact. Be sure to ask for help from the skilled nursing team, thats what they are there for.

Breast milk is digested quickly. Frequent feeding is not a sign of inadequate milk supply. It is not abnormal for a breast-fed infant to continue to nurse every 1 1/2 to 3 hours, especially during the day, for several months. Do not let your baby sleep through feedings until your milk supply has been developed. Breastfeeding has no convenient measurement of how much the baby is getting. Breastfeeding is a learned skill for both baby and mother and it is common for mothers to be anxious about the amount of milk their baby is getting. Reassuring signs after the first 24 hours are: the baby is eager to nurse the baby nurses at least 8 times every 24 hours mom can hear the baby swallowing during nursing mom may notice milk dripping from the opposite breast the breasts may be softer after nursing the baby wets 6 or more times every 24 hours the babys urine is pale yellow, not deep yellow or orange the baby is gaining weight

It is very difficult to over-feed a breastfed baby. Babies, unlike adults, tend to stop when they have had enough. Using a breast pump allows mothers to collect milk at a convenient time for later use, and it allows fathers to be more active participants in the babys care. A pump can also be used to maximize milk production by pumping immediately after a feeding. It can also be used to collect milk if mom is separated from the baby. Freshly expressed breast milk can remain at room temperature (66 to 72 F) for four hours, 5 to 7 days in the refrigerator (32 to 39 F), 3 to 4 months in a refrigerator freezer, and 6 to 12 months in a deep freezer (0 F). Once thawed, breast milk should not be refrozen. Breast milk may be stored in the refrigerator for up to 48 hours. Frozen breast milk is good for about a month and up to 3 to 6 months if in deep freeze. It is helpful to store milk in glass, rigid plastic or special plastic storage bags in the approximate amounts used in single feedings. Breast milk can be thawed by moving it to the refrigerator and then placing it in warm water with frequent rotation. Microwaving heats unevenly, damaging the proteins, and could burn your babys mouth. Breasts should be washed with water (daily shower) only. To prevent drying or cracking of her nipples, mom may use a small amount of lubricant, such as lanolin, or expressed breast milk. Mom should wear a good, supportive bra, preferably a nursing bra. Exclusive breastfeeding for the first six months of life should be encouraged but breastfeeding does not have to be all-or-nothing. The parents can supplement with infant formula, although they should start with breastfeeding. Lots of helpful links about breastfeeding are available at: http://www.aap.org/healthtopics/breastfeeding.cfm

Bruising: Bruising of the newborn is common. Bleeding in the scalp (cephalohematoma) is also frequently seen and can take months to reabsorb. Babys Breasts: Enlarged breast tissue (possibly leaking) is common in both boy and girl newborns. It is the result of maternal hormones and usually resolves by 8 weeks. Burping: Burping helps rid the baby of uncomfortable swallowed air. Some babies need to be burped 2-3 times during a feeding. Car Seat: More children ages one to nineteen years die from car crashes than any other way. A car safety seat must be used at all times when an infant or small child rides in a car, including the ride home from the hospital. It is the law in every state. The safest place for a child is usually in the middle of the back seat, correctly buckled into a child safety seat. Infants and children less than 12 years should never be placed in the front seat of a car equipped with a passenger side airbag. Infants should ride in a rear-facing infant car seat until they have reached at least 1 year of age and weigh at least 20 pounds. Rear facing child seats can be used for a longer period of time if the infant has not yet developed good head control. Built in car seats are not designed for infants. Not all seats fit in all cars. Parents must shop carefully, study the directions, and install the seat properly. Parents can sometimes find help installing seats through the local fire department / EMS, or through programs offered by insurance companies. A nice summary of products and recommendations is available at: http://www.aap.org/family/carseatguide.htm Circumcision: Merely keep the area clean and covered with petroleum jelly (Vaseline) until the site is healed, about two weeks. If you need to wash the area at all, use only water and no wipes. Parents may notice a thin yellowish material on the tip of the penis. This is normal. Clothing: Parents tend to over-dress rather than under-dress their babies indoors as well as out. As a rule of thumb, a baby needs about the same number of layers or thickness of clothing as you do, or at most one layer more. Cotton is the material of choice. Children are not objects; they are not our creation. They are not ours; they are us. Penelope Leach

Colic: 10 to 20% of otherwise healthy babies have periods of sudden crying and extreme fussiness, often lasting for hours. The onset usually occurs by two weeks of age; the cause is unknown. It usually resolves spontaneously by 3 to 4 months of age. No medicine has proven effective. Colicky babies grow to be just as happy and healthy as children who do not have colic. Colic can be very stressful on the parents. They need to do their best to avoid fatigue and exhaustion. If they can, they should nap when the baby does, and get some help with household chores. A babysitter can be helpful as well, so mom and dad can have a little time off. Congestion: Mild nasal congestion can be due to normal mucous secretions. Symptomatic medications (decongestants and antihistamines) used by older children and adults should not be used in children under 6 months of age. Salt water (or tap water) nose drops and a bulb syringe can be used to clear the infants nose. A vaporizer or humidifier is also often helpful. Irritability, fever (100.4 rectally or higher), deep cough, difficulty breathing, or poor feeding are all reasons to have the baby seen by a healthcare provider. Constipation: If stools are persistently hard and difficult to pass, a tablespoon of prune juice or apple juice may be added to one bottle of formula per day. If this does not help, the baby may need to be seen by a healthcare provider. (See Bowel Movements) Contraception: No one can predict with any confidence when a woman might become pregnant again. Breastfeeding is not a reliable means of contraception. Women can get pregnant while breastfeeding, even if they are not menstruating. Birth control pills (progesterone only) may be used while breastfeeding. The woman should discuss the options with her healthcare provider. Cradle Cap: Also called seborrheic dermatitis. It is a scaly, oily crusting of the scalp. Sometimes it is associated with a rash of the eyebrows, behind the ears, and around the nose. Gently brushing the scales out after washing the hair daily is usually sufficient to control this condition. It generally gets better by itself in the first few months of life. Crib (bassinet, bed): Federal safety standards require that all cribs built after 1974 have spaces between the crib bars no wider than 2 3/8 inches. This prevents the baby from getting stuck between the bars. The mattress should be firm and flat. There should be no pillows or stuffed animals that could block the babys breathing. Do not use very bulky quilts or blankets. Cherishing children is the mark of a civilized society. Joan Ganz Cooney 6

Crying: Crying is the babys only way of communicating. A baby seldom cries for no reason (except maybe in the case of colic). Hunger, cold, soggy diapers, intestinal discomfort, and the need for physical contact are common causes of an infant crying. Parents should respond to their baby as though she is trying to speak, rather than simply crying. Babies average over 2 hours (and up to 4 hours) a day of crying in the first 2-3 months. You cannot spoil a newborn. The more quickly and consistently parents respond to their baby, the less the baby will cry in the long run and the sooner the baby will begin to use non-crying language such as coos, babbles, and facial expressions to communicate needs. Ways to help soothe a crying baby after things like wet diaper or hunger are addressed include: Rocking your baby Swaddling (tends to work best for newborns) Singing or talking to your baby Walking or taking a stroller ride with your baby Rhythmic noise / vibration or white noise (i.e. a radio in between stations) Burping to relieve swallowed air (which may both happen as a cause and consequence of crying)

Day Care: A consistent one-on-one relationship is ideal for infants. However, a good day care program can offer some significant advantages. The day care center should be smoke-free. However, children in group environments are exposed to more infections. Lots of information on selecting a day care and local regulations is available at: http://www.aap.org/healthtopics/childcare.cfm Dehydration: Signs of dehydration include decreased urine output (less than 4 wet diapers in a 24 hour period), dry mouth and lips, sunken anterior fontanel, and decreased activity. Usually there is a reason for dehydration such as vomiting or diarrhea or refusing to eat. A doctor or nurse should be contacted if the baby might be dehydrated. Depression: More than half of all new mothers suffer from the baby blues with occasional feelings of sadness and anxiety. However, some mothers suffer from much more debilitating feelings of hopelessness and helplessness that make it nearly impossible to properly care for her baby and her self. Professional help can make all the difference in treating post partum depression.

Diaper Rash: If a rash develops, exposure to air is the most important aspect of treatment. The parents may try a zinc oxide cream (Desitin, Balmex), or a petroleum jelly based ointment (A&D, Triple Paste). If the rash persists, the baby should be seen. Diaper rashes usually come in two common forms irritant and yeast. With irritant, the skin folds are generally spared. With yeast (candidal) infections, the intertriginous skin folds are involved and satellite lesions are present. Diapers: Cloth or unscented disposable diapers are both acceptable. Change your babys diaper whenever it is soiled or wet, which occurs 6 to 8 times a day on average. Ears: Avoid Q-tips in the ear canal. Never put anything smaller than your elbow inside an ear. Equipment: Essential equipment includes: Car Safety Seat Crib Bottles, Nipples & Bottle Brush Diapers Diaper and Bottle Bag Thermometer (rectal)

Other helpful equipment would include: Bathtub Changing Table Front pack or carrier Vaporizer / Humidifier Infant Seat Nasal Suction Bulb Pacifier Stroller Swing Toddler Nail Clipper

Erections: These occur commonly in newborn boys. Often they are triggered by a full bladder so watch out! Nothing you ever do for a child is wasted. Garrison Keillor

Eyes: The eyelids are often puffy in newborns. If there is significant discharge, redness, or swelling, the baby should be seen by her healthcare provider. In the beginning, a baby may have occasional uncoordinated eye movements and look cross-eyed (exotropia or esotropia). By 4 months, the eyes have conjugate movements. A newborn can most clearly focus on objects 8 to 12 inches away. This is the face-to-face distance in breastfeeding. The colors babies see best are red, black, and white. Clear color and binocular vision is usually established by 6 months of age. Eye Color: Eye color is usually established by 6 months of age, however the appearance of eye color can be affected by many environmental factors and some people experience changes in eye color over the course of their lives. Fever: A rectal temperature of 97.7 or 100.4 (rectal) is considered abnormal in an infant. Any child 2 months old or younger with an abnormal temperature should be seen immediately. Fluoride: Fluoride helps infants and children build strong bones and teeth and prevent cavities. However, fluoride is not an issue until six months of age. Fontanel: The anterior fontanel usually closes by 15 to 18 months. Foreskin: The uncircumcised penis does not require any special care. The foreskin should not be forcibly retracted. Leave it alone. It is normal for the foreskin to be adhered to the glans (head of the penis) and not be retractable even up to 17 years of age. (When it is retractable, gentle cleaning with the foreskin pulled back is all that is recommended.) Formula: There are three common types of formula, cows milk protein-based (e.g., Similac, Enfamil, Gerber, etc.), soy protein-based (e.g., Isomil, Prosobee, etc.) and casein-hydrolysate-based formulas (e.g., Nutramigen, Alimentum, Progestimil, etc.). Typically, a cows milk-based formula is offered as first-line nutrition. Almost any commercially available formula is satisfactory, however, low iron formulas are not recommended. Iron formulas do not cause constipation. Parents should not use whole milk or any other substitute for an actual infant formula. The formula must be made according to the manufacturers directions. All formulas prepared from powder should be fed immediately or refrigerated and fed within 24 hours of preparation. Formula should not be left unrefrigerated for more than four hours. Never refreeze it.

Formula Feedings: If breastfeeding is not feasible, a prepared formula is certainly adequate, and should be one with iron supplementation. Concentrated and powder formulas are less expensive; ready to feed is more convenient. Room temperature bottles are fine. Formula should never be heated in a microwave as uneven heating may occur and can lead to burns. A babys appetite may vary, but a normal newborn takes 2 to 3 ounces per feeding by the end of first week, increasing to 5 to 7 ounces by three months of age. It is usually not necessary to sterilize or boil equipment or bottles; dishwasher cleaning is excellent. Most water sources are acceptable without boiling. Still, many parents prefer to boil the babys water for the first few months. A baby should never fall asleep with a bottle as it can lead to severe dental decay. Handedness: Babies are essentially ambidextrous. Although an infant may go through phases where she seems to prefer a particular hand for certain activities, handedness is usually not set unequivocally until the second or third year. Head Control: Good head control does not develop until about 6 months. A backpack carrier should not be used until the baby has developed this head control. Help: Whether they include the mother-in-law, the spouse, a sister or next door neighbor, helpers should look after mom and the chores so that mom can look after the baby. The Armed Forces YMCA and NPST (New Parent Support Team) are also available to assist. Contact a social worker for more details and resources. Hepatitis: The babys first immunization is for the prevention of Hepatitis B and is usually given before discharge from the hospital. Hiccups: Hiccups are common with infants and are nothing to worry about. Hydrocele: A hydrocele is a nonpainful collection of fluid around one or both testes. Most resolve spontaneously by 12-15 months. A hundred years from now it will not matter what my bank account was, the sort of house I lived in, or the car I drove but the world may be different because I was important in the life of a child. Unknown

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Illness: Temperature of 100.4 or 97.7 (rectal) should prompt a visit to your health care provider if your infant is under 2 months old. Below are some other signs of illness in infants that necessitate evaluation by a health care provider: Refusal of feedings Repeated or projectile vomiting (not just spitting up) Green vomitus Blood in the bowel movement Decreased urination Increasing jaundice Difficulty breathing, or breathing very quickly Inconsolable, fretful, extremely irritable, very fussy Fits or convulsions Listlessness or lethargy

Immunizations: Remind parents to always bring their babys immunization shot record with them to all of the well child appointments. Iron: Low iron infant formulas should not be used. It is a myth that iron in formula causes constipation or stomach problems in infants. Jaundice: About 2/3 of newborns become clinically jaundiced. However, if jaundice is clinically apparent within the first 24 hours of life it is likely due to either a hemolytic process or sepsis. The risk of bilirubin encephalopathy (kernicterus) is extremely low in infants weighing greater than 1500 gm with nonhemolytic hyperbilirubinemia if the serum bilirubin is kept below 24 mg/dl. Phototherapy is the standard therapy for hyperbilirubinemia that warrants treatment. Phototherapy causes unconjugated bilirubin to convert to a more water-soluble isomer, which facilitates biliary excretion. Medicine: A baby less than 2 months old should not receive any medicine, including acetaminophen (Tylenol, Tempra) and cold remedies unless directed by a health care provider. Milk: Dont feed the baby cows milk before her first birthday. Cows milk is not readily digestible by infants and contains excessive amounts of proteins and minerals, particularly phosphate, which may overstress immature kidneys. Cows milk does not contain the proper amount of iron and may contribute to iron deficiency anemia by causing irritation of the lining of the stomach and intestines and subsequent gastrointestinal blood loss. Molding: In passing through the birth canal, a babys pliable head may be molded into an unusual shape. It will become more normal over the first several days and weeks of life.

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Nails: Newborn fingernails are sharp and they grow very fast. A clipper can be used, but can easily cause bleeding when the skin is mistakenly clipped. Injury, and permanent damage, has been reported with the use of scissors. An infants nails should never be bitten off. An emery board is a safe, convenient way to keep nails short. Covering with cotton mittens or socks can be helpful too. A newborns toenails do not grow as fast. However, toenails are quite often surrounded by heaped-up skin. Ingrown toenails are rarely a significant problem in newborns. Pacifier: Some babies can manage well without a pacifier. However, like thumb sucking, the pacifier is certainly helpful for many babies who are difficult to comfort in any other way. Babies have a need for non-nutritive sucking in addition to that which they perform while feeding. The attachment to the pacifier tends to decline with time and is almost always given up by the start of school. Pacifier use during sleep is associated with a reduced risk of SIDS. Panting: Panting as the baby falls asleep is common and is nothing to worry about. Penis: See Circumcision or Uncircumcised. Periods: New mothers may not get periods while nursing. This does not mean the new mother cannot get pregnant. Pets: It is hard for a pet thats always been treated like a baby to suddenly move over when a real baby appears on the scene. If the pet seems hostile toward your new arrival, the parents must keep it away from the baby until the pet has adjusted. Hopefully, they will not need to find another home for their pet. Reading: It is highly encouraged to start reading to babies early. This is a good habit that may help promote development. Reflux: See Spitting Up. Rolling Over: By 6 months a baby should be able to roll over. Often it happens earlier. The baby should never be left unattended on a changing table, chair, sofa, or any other elevated, flat surface. If you are a parent, recognize that it is the most important calling and rewarding challenge you have. What you do every day, what you say and how you act will do more to shape the future of America than any other factor. Marian Wright Edelman

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Safety in the Home: The range of potential hazards in the home is vast and exposure to these varies as a child develops. Baby proofing the home includes the following: Smoke detectors should be present on every level of the home and near sleeping areas. Their batteries should be changed twice a year. Every house should have an escape plan that includes a designated meeting place. Carbon monoxide detectors should also be in the home. To help prevent tap water scalding injuries, the maximum water temperature should be no higher than 120 F (49 C). Stove guards should be considered. Safety gates can prevent falls on stairs. Infant walkers should not be used. There should be physical barriers to prevent a toddler from falling out a window. All sockets should be covered with safety plugs. Swimming pools should be completely surrounded by fences. Store all products in their original containers. Lock medicines and poisons high, out of sight and reach of children.

Shaken-Baby Syndrome: Shaken-baby syndrome is caused when a baby is shaken in a violent, uncontrolled manner by a caregiver who is angry with the baby, usually when she wont stop crying. Shaken-baby syndrome causes retinal hemorrhages, subdural hematomas, severe brain damage, rib fractures, and can be life threatening. Shoes: Until the baby begins walking outdoors, she doesnt need to wear shoes. Sibling Rivalry: The arrival of the baby can be stressful for the older children, especially for those less than 3 years old. Parents should not make any sudden demands or changes on the older child at this time. For example, it is not a good time to change rooms, begin toilet training, or start daycare. Parents should enlist the older siblings as helpers and provide them with some exclusive time daily. These should be frequent, in short amounts, and appropriate to the childs developmental level. Correct infant care is vital to producing super babies. Super babies are similar to regular babies except they belong to you. P.J. ORourke

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SIDS: Sudden Infant Death Syndrome (SIDS), an idiopathic cause of infant death, is the number one killer of infants in the US during infancy beyond the neonatal period. SIDS is defined as the sudden death of an infant younger than one year, which remains unexplained after a thorough case investigation, including complete autopsy, examination of the death scene, and review of the clinical history. The incidence peaks between two and three months of age. The risk factors: Prone sleeping position Sleeping on a soft surface Maternal smoking during pregnancy Overheating Late or no prenatal care Young maternal age Preterm birth and/or low birth weight Male sex Black and Native American

Recommendations: Supine sleeping position (back to sleep) Firm sleep surface Soft objects removed from the crib Avoid loose blankets and sheets Smoke free environment Sleep separately from the parents, but nearby o Crib in parents bedroom, if possible Consider offering a pacifier at nap time and bedtime Avoid overheating o Keep the room warm enough so a lightly clothed adult would be comfortable

Sitting: A baby generally sits well with support by about 5 months. By 7 months a baby generally sits well without needing any support. Perhaps the greatest social service that can be rendered by anybody to the country and to mankind is to bring up a family. George Bernard Shaw

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Skin: Most newborns develop a skin rash of some sort. A few of the more common ones are: Red patches at the base of the skull (stork bites), on the eyelids, and on the forehead (angel kisses) that usually fade in the first few years of life. Mongolian spots which are slate grey, brown or purplish areas found on the lower backs and buttocks of some babies. These usually also fade with time. Neonatal Acne, which refers to pimples on the face that occur at about one month of age in about 30% of newborns. They gradually disappear, usually by 4-6 months of age and do not require any medications. Peeling and wrinkling, which is self-limited, does not require treatment. Milia, which are tiny white bumps on the faces of 40% of newborns. They are caused by blocked pores, and will disappear without treatment in 1-2 months. Erythema Toxicum, which refers to harmless to 1 inch reddish blotches with a small white lump in the center. They may look like insect bites, and occur in about 50% of newborns. They will resolve on their own, usually within 2 weeks. Dry Skin is very common. Bathe your baby infrequently (2 or 3 times per week), and lubricate the skin frequently, especially after a bath, with lotion, cream or ointment containing no perfumes. Soap is rarely needed. See Bathing. Drooling Rash, on the chin or the cheeks, is very common around 4-6 months when drooling is prominent. Keep your babys mouth clean and dry, and the rash will go away.

Sleep: The average baby sleeps 15 hours out of 24 at age 3 weeks; some sleep more, some less. Most babies are sleeping through the night feeding by 4 months of age. Sleep Deprivation: Every newborn awakens frequently. Parents get their sleep in bits and pieces. When the baby naps, mom and dad should also. If mom and dad do not take care of themselves, they will not be able to take care of their baby. Sleeping Position: The American Academy of Pediatrics recommends that infants be placed on their backs to sleep (back to sleep, tummy to play). Studies have shown a decrease in Sudden Infant Death Syndrome (SIDS) with this positioning. There is no evidence that sleeping on the back is harmful to normal infants.

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Smiling: Brief smiles along with other spontaneous grimaces are common in the first few weeks. However, deliberate smiling usually begins by 2 months. Smoking: Children who live in homes where there is smoking have more respiratory infections, more otitis media, more allergy problems, and a higher incidence of asthma and gastroesophageal reflux disease. Maternal smoking is a risk factor for Sudden Infant Death Syndrome. The patch is safe to use while breastfeeding. Smoke and carbon monoxide detectors should be in every home. Sneezing: This is common in infants and does not indicate infection or allergies. Soap: Avoid harsh soaps like deodorant and scented soaps. A mild soap such as unscented Dove or Tone is preferable. In fact, soap is usually not needed at all. Socializing: The baby may be taken outside whenever the weather is pleasant. It is probably prudent to avoid crowds until 6-8 weeks of age. Always avoid people who are sick. Good hand washing is the best way to avoid spreading any illness. Solid Foods: During a babys first year, solid foods should take second place to breast milk or formula. Solid foods should not be introduced until 4 months at the earliest for formula fed-babies, and 6 months for breast-fed babies. Until a baby is 12 months old, breast milk or formula should be the main source of nutrition. Food should be introduced one at time in small amounts. Some foods are more likely to be allergenic. Dairy products, other than formula, should not be introduced before 12 months, eggs before 24 months, and peanuts, tree nuts, and seafood no earlier than 36 months. Speaking: Most babies say their first word by 12 months and have at least 3 words by 15 months. Spitting Up: Most babies spit up (reflux) somewhat after feedings. As long as the baby is gaining weight adequately, this is usually not a worrisome problem. Spitting up decreases with age. Spoiling: It is impossible to spoil an infant. Frequent touching, holding, and comforting actually foster security and confidence and lead to independence and establish the ground work for good self-esteem. Sun: A babys skin is very sensitive so avoid direct sun exposure. Most sunscreens are not recommended on babies under six months. The simplest and best way to protect a baby or childs skin is to keep her out of direct sunlight.

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Tear Duct Obstruction (dacryostenosis): Very common. 30% of the time, it is bilateral and results in chronic tearing and discharge. Try warm compresses and massaging the area top to bottom between the inside corner of the eye and the bridge of the nose several times a day. If it persists for longer than 9-12 months referral to pediatric ophthalmology is warranted. Tears: Tears are usually not produced with crying until at least one month. Teeth: The first teeth usually erupt between 6 to 12 months. When baby teeth come in depends more on heredity than anything else. Some babies are even born with teeth. The bottom two front teeth usually arrive first. Teething does not cause significant fevers. Babys teeth should be cleaned at least once a day (e.g., before bed time). A washcloth or soft brush without toothpaste should be used. The American Academy of Pediatric Dentistry recommends that a childs first dental visit be scheduled shortly after the first teeth erupt or by 12 months of age. Never put a child to bed with a bottle as it can cause tooth decay. Testes: About 3% of newborn boys have a testis that has not completely descended into the scrotal sac. In the vast majority of boys the testis descends spontaneously. If the testicle is not palpable at age 6 months, referral to pediatric urology is indicated. If the testicle is palpable but still undescended at age 1 year, referral is indicated. If neither testis is palpable, pediatric endocrinology should be consulted immediately. Thrush: Thrush is a Candida infection that can cause a white patchy covering on the tongue, insides of the cheeks, and roof of the mouth. These resemble mild curds but do not rub off easily. Thrush is quite common and although easily treated, often returns. If mom is breastfeeding, she will need to be treated for signs of breast/nipple thrush. Thumb Sucking: This is a self-comforting measure (like pacifier use). It is generally not harmful and tends to disappear on its own. Tongue-Tied (ankyloglossia): In children born tongue-tied, the frenulum connecting the underside of the tongue to the floor of the mouth is too tight. As the babys tongue grows and moves, this tissue is stretched. By the age of one, the child should be able to stick out his tongue past the gum line. Babies who cannot breastfeed may need their frenulum surgically snipped, but this is uncommon. Toys: Infant toys, such as rattles, squeeze toys, and tethers, should be large enough so that they cannot enter and become lodged in an infants throat.

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Travel: Prudent traveling with your infant is generally OK. It would be wise to first discuss travel plans with a doctor or nurse. Umbilical Cord: Clean the cord where it meets the skin 2-3 times daily with a Qtip dipped in rubbing alcohol until the stump falls off (typically by 2 to 3 weeks). Avoid covering the cord with the diaper as this delays drying and increases the chance of infection. Do not submerge the area underwater in a bath until after the cord has come off. Sponge baths may be given prior to the cord coming off. Umbilical Hernia: A small protrusion around the belly-button is not uncommon. This hernia will usually close on its own by 2-3 years. Rarely, a surgical repair is necessary. Coins, taping, and belly bands do not speed up this closing. Uncircumcised: Boys who are uncircumcised do NOT require any special care. This is the natural state and the foreskin is naturally adhered to the glans (head of the penis). Do NOT try to retract the foreskin. Leave it alone. Please refer to the AAP handout on Care of the Uncircumcised Penis. Vaginal Discharge: Because of the withdrawal of the mothers hormones, some baby girls will have slight spotting or discharge from their vagina for the first few days after birth. A whitish, mucous discharge may persist for months. These discharges are all normal. Vitamins: Infant vitamin supplements usually are not necessary, except for vitamin D in breast-fed infants starting at 2 months. Vomiting: All babies spit up but forceful vomiting is not normal. If the vomit is greenish, bright yellow, bloody or looks like coffee grounds, the baby should be seen. If the babys tummy becomes hard, distended, or tender to touch, the baby should be seen. Walkers: Infant walkers are unsafe at any speed. The combination of decreased supervision and increased mobility makes the infant walker a dangerous device. Also, studies have shown that the use of the walker may delay gross motor development. The American Academy of Pediatrics strongly discourages the use of infant walkers. Walking: Most babies take their first unaided steps by 12 to 15 months. Water: Babies get all the water they need in breast milk or infant formula. Do not supplement a babys feedings with any additional water. Adults are obsolete children. Dr. Seuss 18

Water Heater: To avoid scalding a babys tender skin, the thermostat on your water heater should be set so that the water coming out of your faucet is less than 120 F (49 C). Weaning: Weaning off breast / bottle feeding is a process, not an event. Weaning should be gradual, over a period of several weeks to months. Weight Loss/Gain: All babies lose weight (up to 10%) in the first few days after their birth. Almost all babies have gained back to their birth weight by 2 weeks. Thereafter, normal newborns gain 20-30 g/day, doubling their birth weight by 4-5 months and tripling it by one year of age. Adequate feeding is best judged by appropriate weight gain. Well Child Visits: If at all possible, both parents should come to their babys checkups. It is helpful if the parents write down their questions ahead of time. The shot record (yellow card) should be accorded the status of a passport and be brought to each well child appointment. Routine (well baby) checkups during the first year typically occur at: 2 days after discharge 2 weeks old 2 months old 4 months old 6 months old 9 months old 12 months old

I looked on child-rearing not only as a work of love and duty but as a profession that was fully as interesting and challenging as any honorable profession in the world and one that demanded the best that I could bring it. Rose Kennedy

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Supplemental Reading Heading Home with Your Newborn I Wish Someone Had Told Me Infants and Mothers The First Twelve Months of Life What to Expect the First Year Your Baby and Child The Baby Book Caring For Your Baby and Young Child Dr. Spocks Baby and Child Care Parents Book for Raising a Healthy Child Laura Jana & Jennifer Shu Nina Barrett T. Barry Brazelton F. Kaplan Arlene Eisenberg Penelope Leach William Sears Steven P. Shelov Benjamin Spock Morris A. Wessel

Videos What Every Baby Knows Your Baby and Child T. Barry Brazelton Penelope Leach

Children do not need superhuman, perfect parents. They have always managed with good enough parents: the parents they happen to have. Penelope Leach

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